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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204161
Report Date: 08/30/2024
Date Signed: 08/30/2024 11:31:32 AM


Document Has Been Signed on 08/30/2024 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GREEN GABLES CARE HOME VIIFACILITY NUMBER:
107204161
ADMINISTRATOR:SHEAKALEE, MARSHAFACILITY TYPE:
740
ADDRESS:1422 ASH AVENUETELEPHONE:
(559) 298-7302
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 3DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator-Mario RamosTIME COMPLETED:
11:40 AM
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On 08/30/24 Licensing Program Analysts (LPA) J. Leffall and M. Yang arrived unannounced to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit, and was greeted by Staff (S1) Gerardo Diamat. LPAs was granted entry. All 3 residents were present during inspection. Licensee Lorik Sheakalee was called and stated unable to attend inspection. Designee Mario Ramos (D1) arrived shortly after LPA’s arrival.

LPAs toured facility with D1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 8.9 degrees F and refrigerator temperature was maintained at 45 degrees F. Fire extinguisher was observed with a purchase date of: 10/12/23. Fire drill last completed on 6/5/24. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 110.4 and 109.1 in bathroom 1 and 107.9 and110.4 degrees F. in bathroom 2. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. All medications were checked and observed kept locked in the hall closet. Residents’ MARS was reviewed. First aide kit observed with all of the required items. All residents and a sample of staff files reviewed to have all the required documents.


No deficiencies issued during this inspection. Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 09/5/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Designee, whose signature on this form confirms receipt of these report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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